- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $3,090.30 / $6,760.83
| Facility | | $354.81 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $338.84 / $741.31
| Professional | | $208.93 | $338.84 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $6,606.93 / $21,379.62
| Facility | | $446.68 | $6,606.93 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $602.56 / $891.25
| Professional | | $501.19 | $602.56 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,549.93 / $21,877.62
| Facility | | $5,495.41 | $9,549.93 | $21,877.62 |